DHS-7948-ENG   8-24 (3.1.2)

Housing Stabilization Services Eligibility Request

Required field

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Select a reason below to start completing this form.

Exception reason

Check at least two boxes below and upload supporting documentation (only Criminal Background is required when a person has a felony conviction within the last 7 years). Only PDF, Word, Excel, JPG, GIF, PNG, BMP or text files may be uploaded. 

    The file was not added as an attachment.

    Recipient

    DISABILITY TYPE

    Mailing address

    Moving expenses

    *Home means a setting that a participant owns, rents, or leases that is not operated, owned or leased by provider of services of supports. Please verify allowable institutions and provider-controlled settings definitions on the Housing Stabilization Policy page.

    Consultant

    No record found

    Housing Transition/Sustaining Provider

    No record found

    Attachments

    Upload supporting documentation. Only PDF, Word, Excel, JPG, GIF, PNG, BMP or text files may be uploaded.

    Upload the Additional Remote Support Request (DHS-8165). Only a PDF file may be uploaded.

            Submitter

            I understand that I am electronically signing this form by typing my name below. In addition, I attest and certify that I have verified the profile change against an acceptable form of identification and that the information provided above is true and accurate. I understand that my electronic signature has the same legal effect and can be enforced in the same way as a handwritten signature. (MN Stat. §325L.07)

            DHS ONLY

            DHS Reviewer

            DHS Reviewed Qualifications for Service

            Person Centered Plan

            Request Status

            Approved Transition/Sustaining Provider Billing Span

            Moving Expenses

            Managed Care